Provider Demographics
NPI:1992415327
Name:IBRAHIM, HASSAN (PMH NP)
Entity type:Individual
Prefix:
First Name:HASSAN
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:
Credentials:PMH NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5611 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-7956
Mailing Address - Country:US
Mailing Address - Phone:646-761-9279
Mailing Address - Fax:
Practice Address - Street 1:5611 30TH AVE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-7956
Practice Address - Country:US
Practice Address - Phone:646-761-9279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY404631363LP0808X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health